When I left South Africa in 1968 academic medicine was flourishing. The best graduates wanted to pursue academic careers and there was fierce competition for posts in teaching hospitals. Although not in itself a manifestation of profound research the world's first heart transplant had revealed just how sophisticated medicine was in the country. The general medical scene was less satisfactory. Few black doctors were being trained—seven in 1966; 11 in 1967; 10 in 1968—and the distribution of doctors was grossly distorted in favour of white suburbs. This inequality of service was reflected in patterns of health and disease.

At the end of 1995 I returned to join an advisory group set up by the minister of health, Dr N C Zuma, to try to restore a badly depleted and demoralised academic sector. What I found was extremely depressing. The status of academic medicine had declined seriously, the teaching hospitals had been deprived of funds, salaries for academics and those working in the public sector were quite inadequate with a resultant haemorrhage into private practice. Vast numbers of doctors had emigrated. The mix of private and public medicine had changed completely. Only 39% of health expenditure went to the public sector, 61% to the private; one third of all hospital beds were in the private sector.